Your
contact information:
Note: This form is for U.S. Orders only. Contact the Foundation
if you have any questions. |
First Name
(required) |
|
Last Name
(required) |
|
| Shipping
Address Line 1 (required) |
|
| Shipping
Address Line 2 |
|
City, State,
Zip
(required)
|
(city,
state, zip all required) |
| BoatU.S.
Member Number (if applicable) |
|
| How did
you learn about this program? |
|
| Home Phone
|
xxx-xxx-xxxx
i.e. 888-555-4444 |
Work Phone
or Primary Phone
(required) |
xxx-xxx-xxxx
i.e. 888-555-4444 |
|
Fax Number |
xxx-xxx-xxxx
i.e. 888-555-4444 |
E-Mail
Address
(required) |
|
Rental period:
Please select the need date as one or two days prior
to your actual departure date to ensure you receive the EPIRB on
time. EPIRB may arrive as late as 8PM on this date. |
Need Date
- When do you need unit in your possession?
(required) |
< use calendar
to select need date, which should be 1 or 2 business days before you
plan on departing. |
Return Date
- When can you send the unit back to us?
(required) |
< use calendar
to select return date, which should be the first business day that
you can ship the EPIRB back to the Foundation. |
| Your
Boat Information: |
| Boat Name
(if applicable) |
|
| Boat Model
- What best describes the configuration of your vessel? |
|
Length
(in feet) |
|
round to nearest
whole number no decimals |
| Boat Make
(who is the manufacturer?) |
|
| HIN (vessel
factory serial number - put none if vessel does not have one) |
|
| Registration
Number (state number or documentation number) |
|
| Home Port
(or hailing port - leave blank if none) |
|
|
Identifying Markings - visual elements to help identify your
boat - for example, color of your canvas trim, any hull graphics,
flybridge, radar arch, color of your decking, is the name of the
vessel on the hull sides or transom?, what kind of outboard motors?
(required - 255 Characters Maximum) |
Characters
remaining
|
| Number
of Engines (if none, select "none") |
|
| Engine
Type |
|
| Sail Number
(If applicable) |
|
| Hull Color
|
|
|
Trip information: |
Departure
Point
(required) |
|
Destination
(required) |
|
Number
of People On Board
(required) |
|
| Purpose
- what best describes the primary activity of your trip? |
|
| Event Name,
if applicable (i.e. race or cruising rally) |
|
Emergency contact information:
Your emergency contacts will be notified by the Coast
Guard if you activate the EPIRB. An emergency contact may
be a spouse, family member, or friend. Please provide one
name and phone number per space. This person(s) should
not be traveling with you! If you have additional names or phone
numbers, please type that information in the "identifying markings"
field above. |
Primary
Emergency Contact
(required) |
|
Primary
Emergency Contact Phone
(required) |
xxx-xxx-xxxx
i.e. 888-555-4444 |
| Secondary
Emergency Contact |
|
| Secondary
Emergency Contact Phone |
xxx-xxx-xxxx
i.e. 888-555-4444 |
Credit
Card Information:
Note: Your credit card will not be charged until one or two
days prior to shipment of your order. If no EPIRB is available
for the dates you request, you will be notified and your request
will be placed on a waiting list. If you are on the waiting
list and a unit becomes available, you will be notified by phone
and your credit card will be charged only if you accept the order. The name on the credit card entered below must match the Renter's name entered at the top of this page. |
Credit
Card Number
(required) |
do not enter
spaces or dashes, i.e. 4444444444444444 |
Credit
Card Type
(required) |
|
Credit
Card Expiration
(required) |
enter as mm/yy,
for example, 02/06 |
| Note:
This form does not automatically enter your order, nor does it
guarantee availability of a rental unit. Availability of rental
units varies according to seasonal demand. Once you submit
this form, you will receive a contract via e-mail or fax within
72 hours. Our Phone hours are 12PM to 5PM Eastern Time, Monday
through Friday. |
| |
|
